Healthcare Provider Details

I. General information

NPI: 1487264636
Provider Name (Legal Business Name): HEIDI MARIE REBHOLZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PRUDENTIAL DR
JACKSONVILLE FL
32207-8202
US

IV. Provider business mailing address

2190 BUENA VISTA BLVD
VERO BEACH FL
32960-2963
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number820151
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN60600785
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: